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Decreasing CAUTI Through Resilience in
Workflow and IT Redesign
Session 303 – February 15, 2019
Elizabeth Leskovar, MSN, RN, AGCNS-BC; Chris Nemets, MSN, RN, CNML, CNIO
Sparrow Health System
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Elizabeth Leskovar, MSN, RN, AGCNS-BC
Has no real or apparent conflicts of interest to report.
Chris Nemets, MSN, RN, CNML, CNIO
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Local problem and driving forces for action
• Governance, focus and approach
• Specific project description, goals and benchmarks
• Design and implementation
• But it’s not working…now what?
• How health IT was used: timelines, workflows, technology
• Value derived
• Capital and operational expenses
• Lessons learned
• Q & A
Agenda
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• Analyze the effectiveness of an IT-enabled clinical program
to inform improvement plans
• Create and improve IT-enabled, workflow integrated
processes for improving timely removal of urinary catheters
• Use performance data to coach, collaborate, and improve
processes and demonstrates improvement in CAUTI rates
and standardized infection ratio (SIR)
Learning Objectives
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About Sparrow Hospital
» Lansing, MI
» 676 licensed beds
» 30,000 inpatient discharges
» 960+ Providers, 6,500+ Caregivers
» 13,519 indwelling urinary catheter orders (2018)
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• Catheter-associated urinary tract infection (CAUTI)
– 500,000 per year; >30% of hospital-acquired infections
(HAIs); 13,000 deaths annually
– Leading cause of secondary blood stream infection
(BSI); ~10% mortality, adds 2-4 days to IP LOS, $0.4B
- $0.5B annually
– CDC recommends QI programs with interventions to
identify and remove urinary catheters that are no
longer medically necessary
• Sparrow had no program in place to address these issues
Local Problem
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• Dec 2012
– IP EMR go-live
• 2014
– Reviewed data showing
CAUTIs
– Explored how EMR
could support CAUTI
prevention
Local Problem
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Epic
IP
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CAUTI Governance
• MSEC: Medical Staff
Executive Committee
• iPAG: iSparrow Physician
Advisory Group
• CPOE: Computerized-
Provider Order Entry
• CDS: Clinical Decision
Support
Physician
Nursing
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• Governance selected the Epic Clinical Program created by
Texas Health Resources (THR)
• Rationale
– Proven results from a HIMSS Davies Award winner
• “Standing on the shoulders of giants”
– Focus on timely removal of urinary catheters
– Easy-to-follow “recipe” to reduce CAUTIs
– Reflected evidence-based practice
– Straight-forward IT build, same EMR system
Focus and Approach
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Does THR’s Clinical Program using physician-facing order sets,
order panels, best practice advisories (BPAs), and nursing
documentation flowsheets reduce urinary catheter line days and
CAUTIs at Sparrow?
• Process Goal (by 12/31/2015)
– Urinary catheter line days by 10%
• Outcome Goal (by 12/31/2015)
– CAUTI (#s and NHSN SIR*) by 20% compared to baseline
year (52 in 2014 and 1.4, respectively)
Project Description and Goal
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* NHSN SIR = National Healthcare Safety Network Standardized Infection
Ratio
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• Knowledge tools
– How-to guide: Prevent catheter-associated urinary tract
infections. Institute for Healthcare Improvement (2011)
– APIC implementation guide: Guide to preventing catheter-
associated urinary tract infections (2014)
– Epic’s CAUTI Clinical Program
• IT tool: Epic, because…
– Existing investment with required functionality
– Workflow integration
– Documentation tools and decision support
– Analytics to measure and improve (Tableau)
Design and Implementation
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People
ProcessTechnology
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Design and Implementation
•Define population
•Identify best
practices
•Determine order set
priorities, participant
requirements, BPA
properties
•Training, reporting,
tracking, adherence
Decide what
good looks like
•Assessment
documentation
•Order sets, care
plans
•CDS tools,
displays
•Policy-supported
workflows
Build the
solution in
EMR
•Application &
integrated
testing
•CAUTI
education
•Communication
•Policy
implications
Test, Talk,
Teach
•iPAG and nursing
leadership sign-offs
•EMR workflow
training
•Put into practice
•Measure, monitor,
adjust
Go-live &
PDCA
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8 Months Later…Not Improving - Why?
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CP Go-
live
CP Go-
live
CAUTI by Month: Jul 2013 to Dec 2014
Foley Line Days: Jul 2013 to Dec 2014
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• Change BPA from physician-facing to nurse-facing
because…
– Catheter management & timely removal is a high
nursing priority
– Better locus of control for documentation and action
• Need right leadership, workflows, usable IT
• Outline the big elements
• Governance structure to drive improvement
Back to the Drawing Board
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APIC (2014). URL: http://apic.org/Resource_/EliminationGuideForm/0ff6ae59-0a3a-4640-97b5-eee38b8bed5b/File/CAUTI_06.pdf
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How Health IT was Used: Timeline
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2014
2015
2016
• Monthly report for
Foley rounds
• New care plan,
patient ed
template
• Single button for
peri-care & Foley
care
• Physician-facing
BPA switched to
RN-facing
• Require
Indication in
Foley order
• Physician-facing
BPA
• RN-facing BPA
• Short-term vs.
Long-term
• New Foley Tray
• CAUTI Reviews
• Peri-Care/Foley
Care Education
• Foley rounds
• Female urinals
• Standardized
urine specimen
collection
Health IT Interventions
Clinical Process Changes
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How Health IT Was Used: Timeline (2)
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• New Foley order set
• Updated GU assessment
and Foley maintenance
documentation
• Hyperlink to policy from
flowsheet
• BPA for care plan and
patient education
• Updated I&O flowsheet
• Require “Nursing Action”
in Foley order set
• Prompt added within GU
Assessment to add Foley
LDA
2017
2018
• New Policy
• Annual LMS CAUTI
Education
• Securement device
• Standardized Foley bag
hooks for IV poles
Health IT Interventions
Clinical Process Changes
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How Health IT Was Used:
Provider Workflow
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» Use standard processes for provider
ordering and documentation
» Short-term vs. long-term Foley
» Required question: Indication
» Prompts nursing action
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How Health IT Was Used:
Nurse Workflow
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» Standardize nursing documentation processes (EMR
flowsheets) to capture Foley insertion data
» LDAs, Care Plan
» Use nurse-facing BPAs to prompt care plan & patient
education
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How Health IT Was Used: Order Sets
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How Health IT Was Used: BPAs
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How Health IT Was Used: Policy
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How Health IT Was Used: Unit-Level
Reports for RN Managers
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How Health IT Was Used:
Coaching & Praising
To coach
To praise
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Value Derived - Process Outcome:
Urinary Catheter Line Days
26847
26091
24590
24666
22000
24000
26000
28000
2014 2015 2016 2017
Foley line days
Foley line days
Linear (Foley line
days)
% reduction from
2014 base year
2015 2.8%
2016 8.4%
2017 8.1%
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RN Facing
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Value Derived: Patient Outcomes
Number of CAUTIs
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# of CAUTIs
%
Reduction
2014
52
2015
35 33%
2016
14 73%
2017
20 62%
2018*
10 81%
*Projected based on YTD data
RN-Facing
Dr-
Facing
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Value Derived: Patient Outcomes:
CAUTI SIR Observed vs. Expected (O:E)
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CAUTI SIR
% Reduction
2014 1.401
2015 0.640 54%
2016 0.376 73%
2017 0.497 65%
2017 Action Plan: Increase
• FTF CAUTI reviews w/ unit
leaders & Inf Prevention
• Weekly Foley chart audits w/
feedback to unit leaders
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Correlation of
Improved Processes
with Improved
Patient Outcomes
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• Fewer Foley line
days
• Fewer CAUTIs
• Lower CAUTI SIR
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35
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7
8
2
17
18
7
12
3
0
10
20
30
40
50
60
2014 2015 2016 2017 2018
CAUTIs
Year
CAUTIs: ICU vs. Non-ICU Patients
Non-ICU
ICU
Value Derived: Patient Outcomes by
Severity of Illness – ICU vs. Non-ICU
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# of
CAUTIs
(non
-
ICU)
# of
(ICU)
#CAUTI
vs. 2014
(non
-
ICU)
(ICU)
Costs avoided
(non-ICU) @
$1,479/CAUTI*
Costs avoided
(ICU) @
$10,197/CAUTI*
Total Costs
Avoided
2014 17 35
2015 18 17 1 -18
$ (1,479)
$ 183,546
2016 7 7 -10 -28
$ 14,790
$ 285,516
2017 12 8 -5 -27
$ 7,395
$ 275,319
2018** 3 2 -14 -33
$ 20,706
$ 336,501
Total 2014-17 54 67 -14 -73
$ 20,706
$ 744,381
$ 765,087
Total 2014
-
18**
57 69 -28 -106
$ 41,412
$ 1,080,882
$ 1,122,294
Value Derived:
CAUTI Cost Avoidance
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* Hollenbeak CS, Shilling AL Am J Infect Control, 2018;
46:751.
** Through July 2018
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Expenses
Pre
-
implementation
Modification
TOTAL
Capital expenses
$ 0
$ 0
$ 0
Operational expenses
$ 18,120
$ 10,035
$ 28,155
Analyst time
$ 2,170
$ 700
$ 2,870
Physician time
$ 3,750
$ 1,875
$ 5,625
RN time
$ 11,200
$5,460
$ 16,660
Training time
$1,000
$ 2,000
$ 3,000
Capital and Operational Expenses
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• When you are stuck, think & look outside the box
• Carefully select the most appropriate end-user to see and
take action on the BPA
• Carefully plan your data needs before implementation
• Ongoing, collaborative PDCA is key to sustainability
Lessons Learned
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Elizabeth Leskovar, MSN, RN, AGCNS-BC
Email: Elizabeth.Leskovar@sparrow.org
Twitter handle:
LinkedIn address:
Chris Nemets, MSN, RN, CNML, CNIO
Email: Chris.Nemets@Sparrow.Org
Twitter handle:
LinkedIn address: https://www.linkedin.com/in/chris-nemets-58214565/
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Questions